Rural Health Clinic

EXAMPLE EMERGENCY OPERATIONS PLAN

EMERGENCY PREPAREDNESS PLANNING STEPS TO FOLLOW TO COMPLETE THE EMERGENCY OPERATION PLAN: 1. This is an Emergency Operation Plan (EOP) template. It includes the sections required by the Centers for Medicare and Medicaid Services (CMS) Condition for Coverage Emergency Preparedness rules effective November 15, 2016. You should adapt the template to your facility’s/organization’s situation and needs. However, the Federal Register, Volume 81, should be reviewed in order to avoid deleting any required language. 2. The contents of the Emergency Operations Plan template are in plain type and comments and instructions are in italics for your convenience. Remove all Italics content once you have finished the Plan and before submitting for review. 3. Consider the hazards that affect your area and complete a (use an all-hazard approach) Hazard Vulnerability Assessment (HVA). A facility may need to consider the danger of hurricanes; tornadoes; flooding, mass power outages; wild fired; blizzards and/or ice storms to name a few. All areas of the country are at risk of some type of severe storms and all facilities can be subject to fires or criminal acts. 4. It is important that your staff know who is in charge when an emergency occurs. Leadership during an emergency should be clearly stated in your EOP. As you do your HVA, consider if the different risks would call for staying in place (SIP), evacuating, contacting staff in the field or clients at home or notifying authorities about clients that may need evacuation assistance. These are actions that should be considered in your EOP. 5. Analyze the ways that you communicate during the normal workday. If those systems failed, what would be the back-up plans? If you would need to delay services or shut down due to an emergency, what are the plans for your clients? Who would provide services? How would you communicate patient information, without violating HIPAA? 6. Make sure that all of your employees are trained in the provisions of this plan so that they can act in an emergency. Hold exercises to rehearse emergency procedures as required by the EOP and document these drills. Where appropriate, make sure clients are informed of the provisions of this plan. 7. Coordinate your plan with the local (County or municipal Office of Emergency Preparedness (OEP) and State or Regional Health Emergency Coordinators – most states should have state-wide or regional coordinators. Review the plan at least once a year and after each actual emergency. Request your local Fire Department and Police Department to assist you in creating or practicing exit drills, facility lock

downs or sheltering in place. Coordination, planning and practice will help make everyone involved informed and prepared should an emergency arise. 8. If your RHC is part of an integrated healthcare system, the RHC may be part of the integrated healthcare system’s emergency preparedness program. Check with system leadership to see if you should develop an independent Emergency Operation Plan. 9. This Emergency Management Plan template should be used as a guide. Each clinic in each community is unique and you should develop a plan that is specific to your community. Thoughtful planning and careful consideration must be used to develop a sound plan to cover your unique facility/organization needs. It is important to remember despite successful completion of all hazards plans, planning is never “final”. It will require your vigilance to make the plan better and more efficient every year.

Table of Review and Approval

Date Reviewed Date Approved

The Emergency Plan (EP) was originally written and approved on ________________. As of November 15, 2017, it is required by the Centers for Medicare and Medicaid Services (CMS) that the Emergency Plan must be reviewed annually. It should also be reviewed and updated when an event or law indicates that some or all of the EP should be changed. The following paragraph applies only if your type facility/organization is required to file the EOP with a government agency. The Emergency Operations Plan dated __________ has been forwarded to the ____________________ (state emergency planning agency) and the ____________________on ______________

TABLE OF CONTENTS ORGANIZATION INFORMATION

I. INTRODUCTION TO PLAN PURPOSE DEMOGRAPHICS

II. EMERGENCY PLAN

RISK ASSESSMENT COMMAND AND CONTROL COORDINATION

III. POLICIES AND PROCEDURES CLIENT, STAFF AND VISITOR TRACKING SYSTEM FACILITY LOCKDOWN STAYING IN PLACE (SIP) PLAN EVACUATION PLAN SUSPENSION OF SERVICES DOCUMENTATION VOLUNTEERS

IV. COMMUNICATIONS

INTERNAL EXTERNAL COMMUNICATIONS WITH CLIENTS AND VISITORS COMMUNICATIONS WITH OTHER HEALTHCARE PROVIDERS SURGE CAPACITY AND SHARED RESOURCES REQUESTING ASSISTANCE

V. TRAINING

VI. TESTING

TABS 1. FACILITY LOCATION MAP 2. FACILITY FLOORPLAN 3. HAZARD VULNERABILITY ASSESSMENT WORKSHEET 4. ORGANIZATIONAL CHART 5. ORDERS OF SUCCESSION 6. RECEIVING FACILITIES 7. STATE AND LOCAL GOVERNMENTAL CONTACTS 8. VENDOR CONTACTS 9. COMMUNICATION SYSTEMS/EQUIPMENT 10. AFTER ACTION REVIEW AND IMPROVEMENT PLAN SITUATIONAL RISKS ANNEXES A. FIRE B. BOMB SCARE C. ACTIVE SHOOTER D. LOSS OF WATER/SEWAGE E. ELECTRICAL POWER OUTAGES F. EXTREME TEMPERATURES G. SEVERE WEATHER H. HURRICANES J. WINTER STORMS K. EXTERNAL HAZMAT INCIDENT L. RADIOLOGICAL ACCIDENT M. BIOTERRORISM THREATS

FACILITY/ORGANIZATION INFORMATION Facility: ____________________________________________________________ Address: ___________________________________________________________ City: _____________________________ State: Zip code: ___________ Phone Number: __________________ E-mail: __________________________ Owner: ___________________________________________________________________ Address: _________________________________________________________________ City: _____________________________ State: Zip code: ______________ Phone Number: __________________ E-mail: ____________________________ Select title Administrator/Executive Director/Chief Executive Officer: ___________________________________________________________________ Office Address: ___________________________________________________________ City: _____________________________ State: Zip code: _____________ Phone Number: __________________ E-mail: ____________________________

I. INTRODUCTION TO THE PLAN In order to provide for changes in demographics, technology and other emerging issues, this plan will be reviewed and updated annually and after incidents or planned exercises. This Emergency Operation Plan (EOP) is developed to be consistent with the Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness Condition for Coverage, effective November 15, 2016. Purpose: To describe the actions to be taken in an emergency or exercise to make sure that the clients, staff and visitors of this facility are kept safe from harm. The safety and wellbeing of the clients and staff take first priority over all other considerations. Demographics

A. This facility is located at _______________________________. A map showing the location is attached as Tab 1.

Describe the facility’s location, and show whether there is more than one building. Include a sketch map that shows the neighborhood and main streets. Also point out any other large landmarks that might help quickly identify your building in relation to the surrounding area.

B. The facility has _______ building(s). There are ___________floors. There is

an access to the roof located at _____________. A floor plan(s) is attached as Tab 2. The facility office is located _____________.

C. The building will have appropriate placement of exits signs, clearly

designated on floor plans. Include a sketch floor plan of the building(s) with exits marked. If the facility has any hazardous materials storage, it should be listed here with the location and how access is obtained.

D. This facility provides _________________________services to clients that are children, adults, older adults, over 85 years old.

List a brief description of your services, example: dialysis and a description of your clients.

II. EMERGENCY PLAN 492.12(a) Risk Assessment 492.12(a)(1)

A. This facility does an annual all hazard vulnerability assessment (HVA Worksheet Tab 3). This EOP is written based on the risk assessment. Changes or additions to the EOP will be made based on the annual risk assessment, gaps identified during exercises or real events or changes in CMS or licensing requirements. A copy of the annual HVA will be kept with the EOP.

B. A copy of the EOP will be kept in the office and the plan will be prominently posted. State where EOP will be kept and where employees can view it.

C. The major hazards that could effect this facility as determined by the all hazard vulnerability assessment are listed in the Annex portion of this EOP.

Command and Control

A. The facility shall develop and document an Organizational Chart (Tab 4). The organizational chart will include a Delegation of Authority that will be followed in an emergency. The Delegation of Authority identifies who is authorized to activate the plan and make decisions or act on behalf of the facility if leadership is unavailable during an emergency. When an emergency happens, the person in charge, as listed in the organizational chart, will be informed immediately. In the event that the indicated person by position is not present in the facility or available, the next person in the Delegation of Authority or the lead person’s designee will assume the in charge position.

B. Depending on the type of emergency, the person in charge will enact the Orders of Succession (Tab 5) for the appropriate emergency policy and procedure. Besides the person in charge, one person will always be assigned to list all clients, visitors and staff that are present in the facility. If the list is originated in electronic form, a printed copy should be made also in the event that electricity is lost or evacuation is required.

C. The person in charge will determine whether to lockdown the facility, shelter

in place or evacuate based on the emergency. In the event that the facility must be evacuated, the temporary location for evacuation and facilities for patient transfer are listed in Receiving Facilities (Tab 6).

D. Only the person in charge can issue an “all clear” for the facility indicating

that the facility is ready to assume normal operations.

Coordination

A. Depending on the emergency, the facility may need to communicate with outside authorities. For immediate threats, like fire or threat of violence, call 911.

B. During activation for an incident or exercise, communications with State, regional and local authorities can be made by contacting authorities listed in Tab 7.

III. POLICIES AND PROCEDURES Facility Lockdown

A. Facility Lock Down means that the staff, clients and visitors at the facility will remain in the facilities’ building(s) with all doors and windows locked.

B. Facility Lock Down can be used in emergencies such as active shooter, escaped prisoners, criminals being chased by police, threat made by a significant other or other unknown person or any other event that threatens the safety of the staff, clients or visitors.

C. The facility will remain in lock down until the authorities or facility person in charge gives an all clear.

D. Each facility should review this plan carefully and ensure that doors are strong and have the ability to fend off someone that is attempting to gain access to the facility. It is recommended that staff, clients and visitors be secured behind at least two locked doors. (Main entrance door and interior room door.)

Shelter in Place (SIP) 491.12(b)(2)

A. Shelter in Place means that the staff, clients and visitors will remain in the facility’s building(s). Sheltering can be used due to severe storms, tornados, and violence/terrorism or hazard materials conditions in the area.

B. Windows and doors will be firmly closed and checked for soundness. Storm shutters, if available, will be closed. If a storm gets very strong, and windows are threatened, staff, clients and visitors will move to interior rooms and hallways.

C. In the event of a tornado warning, staff, clients and visitors will move to interior hallways.

D. If sheltering is used in the event of a hazardous chemical incident, windows and doors will be shut and all fans, air conditioners and ventilators will be turned off. Cloths will be stuffed around gaps at the bottom of doors.

E. The facility will stay in Shelter until the authorities give an all clear or the emergency threat has ended as determined by the person in change.

Evacuation Plan 491.12(b)(1)

A. There are a number of hazards that could cause an evacuation. The most common would be a fire in or near the facilities’ building(s), rising

floodwaters or an evacuation order issued by the police, fire department or other governmental authority

B. The facility person in charge will order an evacuation. C. If the emergency is limited to a single building or area, staff, clients and

visitors will move to a safe distance. D. If the entire facility has to be evacuated staff, clients and visitors will move to

a predestinated evacuation site listed in Receiving Facilities at Tab 6. E. Staff will verify that all staff, clients and visitors are accounted for either at

the evacuation site or listing where they went. F. Notifications to others, by staff, will be done as needed. G. Notification to proper authorities is the responsibility of the person in charge.

A predetermined evacuation site should be listed in Receiving Facilities at Tab 6. The site should be close enough to move everyone there but far enough to be outside the danger. Churches, libraries, public auditoriums, etc are possible temporary evacuation sites. Based on clients, may need to add how they would get to site. Notification to significant others will be done by staff based on demographic of client.

Suspension of Services

A. In the event that the emergency results in the inability of the facility being able to continue providing services at the facility, the facility has a plan for continuity of services.

B. Clients will be notified that the facility will not be able to provide services. C. The facility has pre-identify facilities that can deliver required services. The

facilities are listed in Tab 6. D. The facility is part of an integrated healthcare system, and if the client agrees,

services may be transferred within the system.

Documentation 491.12(b)(3) A. During an emergency, documentation should continue for all clients in the

process of treatment. B. During an emergency, evaluation should be made on whether to start

treatment for clients at the facility when treatment has not been initiated. Document decision and plan of care based on client’s condition and facility’s ability to provide treatment during the emergency.

C. All rules pertaining to the protection of and access to patient information (HIPAA) remain in effect during an emergency.

D. If the facility is using an electronic documentation system, describe the method of documentation to be used during the emergency if the electronic system fails.

Volunteers 491.12(b)(4)

A. Medical volunteers may be used at this facility in the following positions:

_____________________________________________________ _____________________________________________________ _____________________________________________________

B. Non-Medical volunteers may be used for the following positions: ________________________________________________________ ________________________________________________________ ________________________________________________________

If there is a list of volunteers, state where the volunteer information is kept. Remember that during an electricity outage, the information may not be available electronically. A hard copy of the information should be available.

IV. COMMUNICATIONS 491.12(c) Internal

A. A list of all employees, including their contact number and emergency contact is located ________________________________. List where the employee information is kept. Remember that during an electricity outage, the information may not be available electronically. A hard copy of the information should be available.

B. In the event of an emergency that requires notification to staff not on duty, physicians, vendors (Tab 8) or to clients expected to arrive at the facility when it is not operational, notification will be given by (state staff position responsible for the notification). A list of all physicians, including their contact number and emergency contact number is located ________________________________. List where the physician information is kept. Remember that during an electricity outage, the information may not be available electronically. A hard copy of the information should be available. A list of vendors and contact numbers that may be needed during an emergency is attached as Tab 7.

C. In the event that telephone and cell phone services are not available, redundant communications are available. The communication system equipment is listed in Tab 9 with its location. All redundant communication systems are tested monthly. List all means that are used to communicate an emergency status such as: telephone tree, texting, radio, TV, etc.

External

A. Call “911” for an emergency that threatens the safety or life of staff, clients or visitors.

B. This EOP contains the name of corporate and/or ownership persons that must be notified on page, FACILITY INFORMATION.

C. This EOP contains a list of all county, state, and local emergency management persons that should be notified at Tab 6.

D. This EOP contains a listing of contact information for other facilities that can provide required services for clients and a listing of nearby hospitals that can provide emergency services at Tab 5.

Communications with Clients and Visitors

A. During an emergency, (state staff position responsible for the notification) is responsible for notifying clients and visitors about the emergency and what actions to take.

Communications with Healthcare Providers

A. Only the person in charge, or their designee, is authorized to release information on the location or condition of clients. Information may be released to other healthcare providers with consent of the client and consistent with HIPAA regulations.

Surge Capacity and Resources

A. Based on staffing and active cases, this facility may be available to surge to accept clients from other (state type facility) requiring like services. The ESF 8 Hospital ADRC will be notified of surge capabilities.

B. As requested by local and regional ESF 8 governmental representatives, the facility will provide excess supplies and/or equipment not needed for their own use.

Requesting Assistance

A. Should the facility need resources to SIP, evacuate or return to service, assistance should be requested as follows: 1. from the corporate, ownership entity; 2. from the ESF 8 Regional representative(s). The ESF 8 Regional representatives are the Office of Public Health Emergency Response Coordinator (PHERC) and the Designated Regional Coordinators (ADRC and DRCs). These representatives are listed on Tab 7. They work with the counties and State to obtain assistance for facilities during and following emergencies.

V. TRAINING 491.12(d)(1)

A. The current staff will be trained on the new or updated EOP at the time of its

publication. B. All new staff will be trained on the EOP in orientation. C. Physicians, vendors performing services on site and volunteers must be trained on the

EOP. D. Emergency Preparedness training will be conducted annually. E. Documentation of the training on the EOP and annual emergency preparedness

training will be maintained by (state what position is responsible for maintaining the documentation of training, usually Human Resources)

F. Knowledge of EOP and emergency preparedness will be shown by return demonstration, if applicable, and participation in the facility Testing Program.

VI. TESTING 491.12(d)(2)

A. The facility will participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility based full scale exercise will be done annually.

B. In the event that the facility experiences an actual natural or man-made emergencies

that requires activation of the EOP, the facility is exempt from engaging in an individual full scale exercise for 1 year following the onset of the actual event.

C. The facility must conduct a second exercise every year. The second exercise can be

another individual full scale exercise or a tabletop exercise.

D. After full scale exercises, tabletops or actual events, the facility should analyze the response, identify areas for improvement and updated the EOP, if required. A template for review is found at Tab 10.

TAB 1 Facility Location Map Place a copy of the Facility Location Map at Tab 1. Google Map may be used to show Location. TAB 2 Facility Floorplan Place a copy of the Facility Floor Plan at Tab 2. TAB 3 Hazard Vulnerability Assessment Worksheet 491.12(a)(1) Place HVA Template TAB 4 Organizational Chart Place your Organizational Chart here TAB 5 Orders of Succession 491.12(a)(3) Orders of succession ensure leadership is maintained throughout the agency during an event when key personnel are unavailable. Succession will follow facility policies for the key agency personnel and leadership. Identify agency essential functions below and assign a primary person and three successors for each function identified. Key Personnel and Orders of Succession Essential Function Primary Successor 1 Successor 2 Successor 3 TAB 6 Receiving Facilities 491.12(b)(1) Temporary Evacuation site for Office Long Term Evacuation Site for Office: Region Hospitals and Contact Numbers: Transfer Agreement Agencies and Contact numbers: TAB 7 State and Local Government Contacts 491.12(c)(2) List local contacts TAB 8 Vendor Contacts

Medical Equipment/Supplies Name of Supplier: Supplier Address: Supplier Phone Number: Alternate Supplier: Supplier Address: Supplier Phone Number: Pharmacy Name of Supplier: Supplier Address: Supplier Phone Number: Alternate Supplier: Supplier Address: Supplier Phone Number: TAB 9 Communication Systems/Equipment Insert information about primary and alternate communications system Add location and list of equipment used in emergency plan (i.e. flashlight, batteries, etc.) Tab 10 After Action Review and Improvement Plan 491.12(d)(2)(iii) A template for a Homeland Security Exercise and Evaluation Program (HSEEP) After Action Report / Improvement Plan is available at: https://emergency.cdc.gov/training/ERHMScourse/pdf/127961885Hseep-AAR-IP-Template-2007.pdf ANNEX A Fire The primary purpose of the Fire Policy and Procedure is to provide a course of action for all staff to follow in the event of a fire. PROCEDURE: R - Rescue anyone in immediate danger. A - Alert contact the fire department by calling 911. C - Contain the fire. Close all doors and windows adjacent to the fire. Close all fire doors. Shut off all fans, ventilators and air conditioners, as these will feed the fire and spread smoke throughout the building.

E - Extinguish if the fire is small. If an extinguisher is available, it should be aimed low at the base of the fire, and move slowly upward with a sweeping motion. -Never aim high at the middle or top of the flames as this will cause the fire to spread. -If you cannot extinguish the fire, evacuate the building/home immediately. Special Note: The most common cause of death in a fire is smoke, and not the flames. Keep low to the floor and avoid inhaling too much smoke. 1. Call the fire department at 9-1-1. Give exact location of the fire and its extent. 2. Call the Administrator. 3. Assist with patients and visitors if evacuation is necessary. 4. Assign a staff member to meet the fire department in order to direct them to the fire. Assign a staff member to keep a roster of patient, staff and visitors if evacuation is necessary. ANNEX B Bomb Scare Upon receipt of a bomb threat, it is impossible to know if it is real or a hoax. Therefore, precautions need to be taken for the safety of patients, staff and visitors. Procedure: If there is a bomb threat received over the phone, follow these procedures:

1. Keep the caller on the line as long as possible. Ask the caller to repeat the message. 2. Ask the caller his name. 3. Ask the caller where the bomb is located. 4. Record every word spoken by the person making the call. 5. Record time call was received and terminated. 6. Inform the caller that the building is occupied and the detonation of a bomb could result

in death or serious injury to many innocent people.

If possible, during the call: 1. Call the Police Department at 911. 2. Call the Administrator if not present. 3. Organize staff/patient to evacuate premises upon police or administrative order. Once the Police have arrived: -Keys shall be available so that searchers can inspect all rooms. Employee lockers will be searched. If padlocked, padlock will be cut off. -If a suspected bomb is located within the building, the responsibility for investigation will be that of the law enforcement officials having jurisdiction over such matters.

ANNEX C Active Shooter When there is an Active Shooter in your vicinity, you have three options, Run, Hide or Fight. Therefore, precautions need to be taken for the safety of patients and staff. Procedure: Run 1. Have an escape route in mind. 2. Leave belongs (purse, book bag, computer, etc.) behind. 3. Evacuate regardless of if others will follow. 4. Help others to escape, if possible. 5. Do not stop to help or move wounded. 6. Stop others from entering area. 7. Call 911 when safe. Hide 1. Hide out of shooter’s view. 2. Lock door or block entry 3. Silent your cell phone, including vibrate. Fight 1. Fight as a last resort, if your life is in danger. 2. Improvise weapon or throw items at the active shooter. 3. Act with as much aggression as possible. Your life depends on it. Once the Police have arrived, keep hands visible and raise over your head. Provide information about location of shooter, wounded and description of shooter, if known. ANNEX D Loss of Water/Sewerage Procedure: If water supply is suddenly disrupted for any reason, the following steps will be taken by staff on duty during the time of the discontinuation of water supply. 1. All attempts will be made to determine the cause for water disruption and the probable length of shutdown and if a Boil Water has been issued. 2. Obtain a copy of the Boil Water procedures from the Department of Health, Office of Public Health and follow instructions. 3. Use of bottled water and canned juices and other fluids, based on dietary restrictions for consumption by patient. 4. Disposable dishes and utensils may be used during emergencies. 5. If necessary, water can be brought in and dispensed as needed. 6. If it becomes apparent that a water shortage will last for an undetermined length of time, emergency measures may be issued by the county and State OHSEP. 7. Determine if suspension of services is needed. 8. Determine if transfer of patients is necessary. ANNEX E Electrical Power Outages

Procedure: In the event of a power outage, the following steps should be followed: 1. Determine:

a. Amount of time that power is expected to be out b. Whether the power company will take immediate steps to restore power to patient

2. Check if back-up generator is working and supplying power. 3. Determine if secession of services is necessary. 4. Determine if transfer of patients is necessary. ANNEX F Extreme Temperatures The purpose of this policy is to provide precautionary and preventative measures for staff and patients during the hot and humid summer months. Older adults are extremely vulnerable to heat related disorders. Definitions: Heat Exhaustion: A disorder resulting from overexposure to heat or to the sun. Early symptoms are headache and a feeling of weakness and dizziness, usually accompanied by nausea and vomiting. There may also be cramps in the muscles of the arms, legs, or abdomen. The person turns pale and perspires profusely, skin is cool and moist, and pulse and breathing are rapid. Body temperature remains at a normal level or slightly below or above. The person may seem confused and may find it difficult to coordinate body movements. Heat Stroke: A profound disturbance of the body's heat-regulating mechanism, caused by prolonged exposure to excessive heat, particularly when there is little or no circulation of air. The first symptoms may be headache, dizziness and weakness. Later symptoms are an extremely high fever and absence of perspiration. Heat stroke may cause convulsions and sudden loss of consciousness. In extreme cases it may be fatal. Precautionary Procedures: 1. Keep the air circulating. 2. Draw all shades, blinds and curtains in rooms exposed to direct sunlight. 3. Have ample fluids, and provide as many fluids as needed. 4. Turn on fans or air conditioner to increase circulation. 5. Assess patients arriving for services for signs and symptoms. If symptoms of Heat Exhaustion is experienced by staff report symptoms to in Charge staff. ANNEX G Severe Weather It is the county’s responsibility to keep the patients and staff safe at all times. If severe weather strikes, precautions need to be taken to ensure their safety.

Definitions: Watch -- Means that conditions are favorable for a thunderstorm or tornado to develop. Flash flooding may occur as a result of the storm. Warning -- Means that a thunderstorm or tornado has been sighted. If a siren sounds, stay inside and take cover. Procedure: 1. Account for all patients and staff on duty. Make sure everyone is inside. 2. Make sure that windows are locked and secured. 3. Keep all patients, staff and visitors away from windows. 4. Notify patients if services will be canceled. If there is a tornado warning, further precautions need to be taken: 1. Move patients, staff and visitors to interior room without windows or in the bathroom. 2. Gather flash lights and radio. Be sure to listen to weather reports for updates. Do not leave the area until the storm has passed and the warning has lifted. 3. Stay calm and provide reassurance to the patient. 4. If not at patient home, call patient to determine condition and if help is needed. 5. In the event that flooding occurs, notify OHSEP and ESF 8 DRC if evacuation of patient is necessary. ANNEX H Hurricane It is the community’s responsibility to keep the residents and staff safe at all times. If a hurricane is approaching, precautions need to be taken to ensure their safety. Definitions: Watch – Issued for a coastal area when there is a threat of hurricane conditions within 48 hours. Warning – Issued when hurricane conditions are expected in the coastal area in 36 hours or less. Procedure: 1. Notify all patients and physicians that services will be suspended when a (Watch or Warning?) is issued. 2. Notify OHSEP and ESF 8 DRC if evacuation of patients is necessary. 3. Notify ESF 8 DRC that services have been suspended. 4. Provide Patients with a call in number to verify that services have resumed. 5. Provide staff with call in number for re-scheduling of services. 6. Notify ESF 8 DRC that services will resume on stated day and time. 7. If available, notify ESF 8 DRC that surge patients may be accepted. ANNEX I Winter Storms

The purpose of these winter storm safety precautions is to inform staff and patients of measures that should be taken during severe winter weather. The following winter storm safety precautions have been established for all personnel to follow during blizzards, heavy snow, freezing rain, ice storms, or sleet. Precautions: 1. Contact all patients at start of event and during, if event lasts an extended time. 2. Notify OHSEP and ESF 8 DRC if evacuation of patient is necessary. 3. Notify patients if Facility will be closed. 4. Keep posted on all area weather bulletins and relay to others. 5. Verify adequate staff is available to re-open Facility. ANNEX J External Hazmat Incident Procedure: The following actions may be taken in the event of an outdoor chemical spill/hazmat incident. 1. Notify the patients that a hazmat incident has occurred. 2. Shut down outside intake ventilation. 3. Close all doors to the outside and close and lock all windows. 4. Turn off all heating systems. Turn off all air conditioners and switch inlets to the "closed" position. Seal any gaps around window type air conditioners with tape and plastic sheeting, wax paper or aluminum wrap. 5. Turn off all exhaust fans in kitchens and bathrooms. 6. Close as many internal doors as possible in the building. 7. Use tape and plastic food wrapping, wax paper or aluminum wrap to cover and seal bathroom exhaust fan grills, range vents, dryer vents, and other openings to the outside. 8. If the gas or vapor is soluble or partially soluble in water, hold a wet cloth over your nose and mouth if gases start to bother you. 9. If an explosion is possible outdoors, close drapes, curtains or shades over windows. Stay away from external windows to prevent injury from flying glass. 10. Tune into the Emergency Broadcasting System on the radio or television for further information and guidance. 11. Call “911” if patient has difficulty breathing or other life threatening condition occurs. 12. Notify OHSEP and ESF 8 DRC if evacuation of patient is necessary. County officials will make a determination regarding possible evacuation of Facility. ANNEX K Radiological Incident Procedure: The following is the procedure to be followed in the case of a radiological accident.

In the case of an accident at a nuclear power plant or other exposure, the local/state office of emergency services will use the following alert systems: Emergency siren system Emergency scanner system The community will receive a notice from the Emergency Broadcast System on the radio and television. 1. Tune into the Emergency Broadcasting System on the radio or television for further information and guidance. 2. Stay inside of Facility. 3. Tell clients that a radiological incident has occurred that may impact their home. 4. Shut down outside intake ventilation. 5. Close all doors to the outside and close and lock all windows. 6. Turn off all heating systems. 7. Turn off all air conditioners and switch inlets to the "closed" position. Seal any gaps around window type air conditioners with tape and plastic sheeting, wax paper or aluminum wrap. 8. Turn off all exhaust fans in kitchens and bathrooms. 9. Close as many internal doors as possible in the building/home. 10. Use tape and plastic food wrapping, wax paper or aluminum wrap to cover and seal bathroom exhaust fan grills, range vents, dryer vents, and other openings to the outside. 11. If the gas or vapor is soluble or partially soluble in water, hold a wet cloth over your nose and mouth if gases start to bother you. 12. Notify patients if evacuation is needed, one small bag is all that will be allowed. County officials will make a determination regarding possible evacuation of Facility. ANNEX L Bioterrorism Threat A bioterrorism Threat is the accident exposure or deliberate release of viruses, bacteria and other agents that cause illness or death in people, animals or plants. Biological agents can be spread through the air, water or food. They can be extremely hard to detect and may not cause illness for several hours or days. Some agents like smallpox can spread from person to person. Other agents like anthrax are not spread person to person Procedure: The following is the procedure to be followed in the case of a biological threat. 1. Notice of a biological event usually comes from the Department of Health, Office of Public Health (OPH). 2. County OHSEPs and the ESF 8 DRCs are notified by OPH when a biological event occurs. 3. Directions will be received from OPH on how to proceed.

4. Patients with Symptoms that may be the result of the biological exposure will be reported directly to OPH. The report is confidential. 5. Agencies may be directed by OPH to give information to their patients regarding the biological.